national health accounts 2007/2008 : egypt report · office of health, infectious disease and...

NATIONAL HEALTH ACCOUNTS2007/2008 : EGYPT REPORT

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Mission

The Health Systems 20/20 cooperative agreement, funded by the U.S. Agency for International Development (USAID) for the period 2006-2011, helps USAID-supported countries address health system barriers to the use of life-saving priority health services. Health Systems 20/20 works to strengthen health systems through integrated approaches to improving financing, governance, and operations, and building sustainable capacity of local institutions.

September 2010

For additional copies of this report, please email [email protected] or visit our website at www.healthsystems2020.org

Cooperative Agreement No.: GHS-A-00-06-00010-00

Submitted to: Bob Emrey, CTO Health Systems Division Office of Health, Infectious Disease and Nutrition Bureau for Global Health United States Agency for International Development

Recommended Citation: Ministry of Health, Egypt, and Health Systems 20/20. September 2010. National Health Accounts 2007/2008: Egypt. Bethesda, MD: Health Systems 20/20 project, Abt Associates Inc.

Abt Associates Inc. I 4550 Montgomery Avenue I Suite 800 North I Bethesda, Maryland 20814 I P: 301.347.5000 I F: 301.913.9061 I www.healthsystems2020.org I www.abtassociates.com

In collaboration with:

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MESSAGE FROM HIS EXCELLENCY THE MINISTER OF HEALTH

It gives me great pleasure to release the Egypt National Health Accounts for fiscal year 2007/08. Egypt has pioneered the production of National Health Accounts in the region. This National Health Accounts report provides critical information that will be extremely useful as we continue our efforts to reform the health sector.

In addition to showing the sources and uses of health resources within the country, the report highlights some key findings including the need to increase public investments in health; reduce the burden of out-of-pocket spending; pass comprehensive social insurance reform to expand access to quality health services; address the continued high spending on pharmaceuticals; and control and rationalize spending under the government’s scheme to provide care for the uninsured.

The report also highlights the need for the government to institutionalize National Health Accounts so that information on health spending is available on a regular basis and becomes a routine activity of the government. Equally important, we need to put a structure in place to systematically track the flow of resources by program to better understand the cost of services. This information will be used to improve budgeting, planning and policymaking.

I would like to commend General Ahmed Farag, Dr. Meirvat Taha, and the National Health Accounts team at the Ministry of Health for their excellent work. I would also like to thank the National Health Accounts Steering Committee for the guidance and support they have provided for this effort. I would especially like to acknowledge the continued support of our development partners at the United States Agency for International Development and the World Health Organization, which have long supported the development of National Health Accounts in the country. I look forward to future collaborations with key partners to institutionalize National Health Accounts in Egypt.

Dr. Hatem El Gabaly His Excellency, The Minister of Health

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CONTENTS

Message from his excellency the Minister of Health ............................. 3

Contents ..................................................................................................... v

Acronyms ..................................................................................................vii

Acknowledgements .................................................................................. ix

Executive Summary ................................................................................ 11

1. National Health Accounts: Main Findings ......................... 16

1.1 Overview ...................................................................................................... 16 1.2 Egypt in Comparison with Other Middle-Income Countries in

the Region .................................................................................................... 17

2. Flow of Funds ....................................................................... 18

2.1 Financing Sources: Who Pays for Health Care? .................................. 18 2.2 Financing Agents: Who Manages Health Funds? ................................. 19 2.3 Providers of Health Care ......................................................................... 20 2.4 Expenditures at a Sub-system Level ....................................................... 21

2.4.1 Ministry of Health.................................................................... 21 2.4.1.1. MOH Expenditure from 2001 to 2007 .................... 21 2.4.1.2 Trends in MOH Expenditure ...................................... 21 2.4.1.3 MOH Sources of Funds ................................................ 22 2.4.1.4 Uses of MOH Funds ...................................................... 22

2.4.2 Specialized Centers of Excellence ....................................... 23 2.4.3 Health Insurance Organization ............................................ 24 2.4.4 Curative Care Organization ................................................. 26

2.4.5 Teaching Hospitals and Institutes Organization ............... 27 2.4.6 Ministry of Higher Education Hospitals ............................. 27 2.4.7 Public and Private Firms ......................................................... 28

2.4.7.1 Public Firms ..................................................................... 28 2.4.7.2 Private Firms ................................................................... 29 2.4.7.3 Total Firms ...................................................................... 30

2.5 Special Treatment Fund ............................................................................ 31 2.6 Households .................................................................................................. 33 2.7 Health Spending Silos ................................................................................ 34 2.8 Study limitations ......................................................................................... 35

3. Policy Implications of NHA Findings ................................. 36

4. Suggested Improvements to the Health Financing System within the Ministry of Health ................................ 38

Annex A: Table ES-1 Overview of Egyptian Health Sector ................ 39

Annex B: Table ES-2 Sources to Financing Agents ............................. 44

Annex C: Table ES-3 Financing Agents to Providers .......................... 45

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LIST OF TABLES

Table 1: Summary of the Main NHA Findings, 1994/95, 2001/02, 2007/08 ......... 17Table 2: Egypt in Comparison with Other Middle-Income Countries in the

Region, 2008 ........................................................................................................ 17Table 3: Financing Sources of the Egyptian Health Care System, 2007/08 ........... 18Table 4: Financing Agents of the Egyptian Health System, 2007/08 ........................ 19Table 5: Expenditure by Type of Provider and Ownership, 2007/08 ..................... 20Table 6: MOH Budget and Expenditure in Relation to GOE Budget and

Expenditure, 2001/02-2007/08 ........................................................................ 21Table 7: MOH Sources of Funds, 2007/08 .................................................................... 22Table 8: Uses of MOH Funds, 2007/08 .......................................................................... 23Table 9: Uses of Specialized Centers of Excellence Funds, 2007/08 ...................... 23Table 10: HIO Uses of Funds, 2007/08 .......................................................................... 25Table 11: HIO Expenditure by Law, 1994/95, 2001/02, 2007/08 (Million LE) ...... 26Table 12: CCO Uses of Funds, 2007/08 ........................................................................ 27Table 13: THIO Uses of Funds, 2007/08 ....................................................................... 27Table 14: MOHE Hospitals Uses of Funds, 2007/08 ................................................... 28Table 15: Public Firms Sources and Uses of Funds, 2007/08 .................................... 29Table 16: Private Firms Sources and Uses of Funds, 2007/08 .................................. 30Table 17: Public and Private Firms Sources and Uses of Funds, 2007/08 .............. 31Table 18: Number of Beneficiaries of the Special Treatment Decrees, 2007/08 32Table 19: Uses PTES of Funds, 2007/08 ......................................................................... 33Table 20: Out-of-pocket Expenditure by Provider, 2007/08 .................................... 33Table 21: The Payer-Provider Silo, 2007/08 ................................................................. 35

LIST OF FIGURES

Figure 1: Financing Sources of the Egyptian Health Care System, 1994/95, 20/0102, 2007/08 ........................................................................................ 18

Figure 2: Financing Agents of the Egyptian Health System, 2007/08 ............... 19Figure 3: Expenditure by Type of Provider and Ownership, 2007/08 ............ 20Figure 4: MOH Budget and Expenditure share of the GOE Budget and

Expenditure, 2001/02–2007/08 ............................................................... 21Figure 5: MOH Trends of Expenditure, 1994/95, 2001/01, 2007/08 .............. 22Figure 6: Specialized Centers of Excellence Sources of Funds, 2007/08 ........ 23Figure 7: HIO beneficiaries according to the Insurance law, 2007/08 ............. 24Figure 8: Percentage of Population Insured by HIO, 1994/95-2007/08 .......... 24Figure 9: HIO Sources of Funds, 2007/08 .............................................................. 25Figure 10: Private Prepaid Plans as a Percent of Private Expenditure on

Health, 2007/08 ........................................................................................... 26Figure 11: CCO Sources of Funds, 2007/08 ......................................................... 26Figure 12: THIO Sources of Funds, 2007/08 ......................................................... 27Figure 13: MOHE Hospitals Sources of Funds, 2007/08 .................................... 28Figure 14: Special Treatment Beneficiaries as a Percentage of the Population,

2007/08 .......................................................................................................... 32Figure 15: Health Care Providers’ Share of Out-of-Pocket Expenditure,

2007/08 .......................................................................................................... 34

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ACRONYMS

CCO Curative Care Organization

EMRO Eastern Mediterranean Region Office

FP Family Planning

GDP Gross Domestic Product

GOE Government of Egypt

HIO Health Insurance Organization

HS 20/20 Health Systems 20/20

HQ Headquarters

LE Egyptian Pound

MOD Ministry of Defense

MOF Ministry of Finance

MOH Ministry of Health

MOHE Ministry of Higher Education

MOI Ministry of Interior

MOT Ministry of Transport

NGO Nongovernmental Organization

NHA National Health Accounts

OOP Out-of-Pocket

PTES Discretionary Spending Account

SIO Social Insurance Organization

THE Total Health Expenditures

THIO Teaching Hospitals and Institutes Organization

UNDP United Nations Development Program

UNFPA United Nations Population Fund

UNICEF United Nations International Children’s Emergency Fund

USAID United States Agency for International Development

WHO World Health Organization

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ACKNOWLEDGEMENTS

The National Health Accounts (NHA) activity in Egypt is greatly indebted to the leadership, guidance, and support provided by the Minister of Health, His Excellency Dr. Hatem El Gabaly. He has inspired the NHA team to produce a work of excellent quality, ensured that the needed resources were made available, and championed the use of NHA in the internal planning of the Ministry of Health (MOH).

We would like to especially acknowledge the guidance and support provided by General Ahmed Farag, the Minister of Health’s Assistant for Administration and Finance. The NHA team met regularly with General Farag and he was always willing to review their work and provide extremely useful feedback. He has been a strong advocate for the NHA activity.

The NHA Steering Committee, constituted by His Excellency the Minister of Health, was made up of the following members:

• G. Ahmed Farag. Minister’s Assistant for Admin and Finance, MOH

• Dr. Said Rateb, Minister’s Assistant for the Health Insurance Organization, MOH

• Dr. Nasr El Sayed, Minister’s Assistant for Primary Health Care, Preventive Care, and Family Planning, MOH

• Dr. Nasr Rasmy, Minister’s Assistant for Curative Care and Ambulatory Services, MOH

• Dr. Kamal Sabra, Minister’s Assistant for the Pharmaceuticals, MOH

• Dr. Ibrahim Yousry, Head of Human and Social Development Sector, Ministry of Economic Development

• Dr. Mohamed Moeet, Minister’s Assistant for Social Insurance, Ministry of Finance

• G. Ahmed Al Twancy, Prime Minister, Data for Decision Making office

The Steering Committee played an important role in reviewing and coordinating the NHA activity, assisted in building support for NHA study, and supported the NHA team in the collection of data and the interpretation of findings.

While a number of persons assisted with making information available, we would like to explicitly acknowledge the assistance provided by Mr. Mahdy Samy, Director of Budgeting at the MOH.

The United States Agency for International Development (USAID) has been a strong supporter of the NHA activity in Egypt since the first round of NHA in the mid-1990s. We want to acknowledge with sincere gratitude the continued cooperation between USAID and the MOH on the NHA and hope that this partnership will continue in the future. Technical assistance for this activity was provided by the USAID-funded Health Systems 20/20 project.

Over the years, the World Health Organization-Eastern Mediterranean Regional Office (WHO-EMRO) has been another institutional partner and supporter of NHA in Egypt. We wish to acknowledge with gratitude their continuing championship of this activity and thank them for making available Dr. Zine EddineIdrissi to provide technical assistance for this effort.

Finally, we wish to acknowledge the various institutions and individuals without whose assistance this study would not have been possible.

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Prepared by: NHA Team, MOH Department of Planning: Dr. Meirvat Taha Director General, Department of Planning Mr. Khaled Sharawy Data and Information Systems Consultant Ms. Azza Morsy Senior Researcher Ms. Mona El Akkad Researcher Ms. Marsil Waheeb Researcher Mr. Tarek El Genedy Researcher Mr. Ali Abdel Zaher Researcher Ms. Mona Sabry Researcher Ms. Naira El Said Researcher Ms. Eman El Meslamny Researcher Ms. Nafisa Ahmed Researcher Ms. Naja Moustafa Researcher Ms. Salwa Bayoumy Researcher Health Systems 20/20 Team: Nadwa Rafeh, PhD Chief of Party, Health Systems 20/20 Nandakumar A.K., PhD Consultant, Health Systems 20/20

Professor, Heller School for Social Policy, Brandeis University Dr. Mahmoud Farag Technical Specialist, Health Systems 20/20 Ms. Nagwan Hassan Technical Specialist, Health Systems 20/20 Ms. Olivia Emil Project Assistant, Health Systems 20/20 Ms. Joanne Beswick Research Program Manager, Schneider Institutes for Health Policy,

Brandeis University

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EXECUTIVE SUMMARY

This executive summary presents the key findings of Egypt’s most recent round of National Health Accounts (NHA), for fiscal year 2007/08.

NHA is a powerful tool to inform health financing policy as well as monitor the impact of policy interventions. It is a globally accepted approach to collecting, cataloging, and estimating flows of funds in the health system. It is a rigorous classification of the types and purposes of expenditures and of the actors in the health system, and it provides an integrated picture of mobilization, management, and use of health funds in the health system.

Egypt was one of the first low- and middle-income countries in the world to conduct NHA. The first round of NHA was conducted in 1994/95, and the second one in 2001/02. Over the years, the United States Agency for International Development (USAID) and the World Health Organization (WHO) have supported this effort globally and in Egypt. The lack of institutionalization in Egypt has meant that NHA has been conducted sporadically.

Egypt has used findings from the previous NHA studies to inform health policy. For example, both country policymakers and donors used results from the first round to shape the health sector reform strategy. Similarly, the second round of NHA led to a focus on primary health care with a specific emphasis on establishing the Family Health Model.

KEY FINDINGS

Egypt has a pluralistic and fragmented health system with multiple sources of financing, financing agents, and providers. The financing sources include government spending that comes from direct tax revenues, out-of-pocket spending by households as premium payments for insurance as well as direct spending on health, employers’ spending on the health of their employees, a dedicated cigarette tax, and donor assistance. These resources flow through a large number of entities including the Ministry of Health (MOH), the Ministry of Higher Education, the Health Insurance Organization (HIO), other ministries, public sector entities, and nongovernmental organizations (NGOs). The provider market is equally fragmented; the MOH owns and operates a large network of hospitals and outpatient facilities. Other public sector entities, such as the HIO, the Curative Care Organization, and the Universities and Teaching Hospitals and Institutes Organization, all run their own facilities. There is a growing private market composed of hospitals, outpatient clinics, pharmacies, and traditional healers. An important characteristic of health financing in Egypt is the fact that the flow of funds from sources to financing agents and then on to providers occurs along almost mutually exclusive tracts (silos). This makes it difficult to effectively coordinate and manage across ministries, sectors (public and private), and entities.

In 2007/08, Egypt spent 42.5 billion Egyptian pounds (LE) on health, representing 4.75 percent of the country’s gross domestic product (GDP). This translates to a per capita spending of 566.4 LE Household spending financed 60 percent of total health spending, followed by Ministry of Finance spending (35 percent); the rest is accounted for by public and private firms and external assistance. Spending on pharmaceuticals remains high, 26 percent of total health spending in the country.

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1. OVERALL HEALTH SPENDING • Egypt’s health investments are declining and, compared with most other middle-income

countries in the region, Egypt invests a smaller proportion of its GDP on health care.

In 2007/08, Egypt spent 4.75 percent of GDP on health.

The percentage of GDP spent on health is declining: between 1994/95 and 2001/02, spending as a percentage of GDP rose from 3.70 percent to almost 6 percent. However, between 2001/02 and 2007/08, the percentage declined, to 4.75 percent.

Only Algeria (4.49 percent), Libya (2.80 percent), and Syria (3.23 percent) spend less on health as a percentage of GDP, making Egypt one of the lowest spenders on health in the region.

Among middle-income countries in the region, only Syria spends less on a per capita basis than Egypt.

2. COMPOSITION OF HEALTH SPENDING • Of the total health spending in 2007/08, 35.5 percent came from the Ministry of Finance (MOF),

1.7 percent from public firms, 2.2 percent from private firms, 60 percent from households, and 0.6 percent from external sources.

• The MOH is funded primarily by the MOF (93 percent), followed by self-funding (4 percent) and donor funding (3 percent).

• The MOH increased its central expenditures from 20 percent in 1994/95 to 52 percent in 2007/08, while it decreased its regional expenditures from 80 percent to 48 percent within the same time period.

• Public spending remains a small proportion of total health spending.

Public spending comprises only one-third of total health spending and has remained at practically the same level between 1994/95 and 2007/08. Typically, as the income of a country increases, so does the share of public spending on health, but this has not been the case in Egypt.

• As was found in earlier rounds of NHA, the MOH is not the major player in health spending.

Between 1994/95 and 2007/08, the share of the MOH spending to total health spending increased by only two percentage points (from 22 percent to 24 percent.)

Between 1994/95 and 2007/08, spending by the MOH increased from 1.2 billion LE to 10.27 billion LE, an increase of over 530 percent. While this appears significant, it is important to place this within the overall macroeconomic situation in Egypt. The fact remains that, between 2001/02 and 2007/08, the share of MOH expenditures to government of Egypt (GOE) expenditures has actually declined, from 3.87 percent to 3.53 percent.

Compared with other middle-income countries in the region, Egypt invests the lowest percentage of the government budget in health. Algeria (10.7 percent), Lebanon (12.4 percent), Iran (11.4 percent), and Jordan (11.4 percent) all spend a significantly higher proportion of the government’s budget on health.

• The burden of household out-of-pocket spending remains high.

Out-of-pocket spending remains the single largest source of health care financing, accounting for 60 percent of total health spending.

Over the past 15 years, the share of out-of-pocket spending to total health spending has increased from 51 percent to 60 percent.

Of all the middle-income countries in the region, Egypt has the highest out-of-pocket spending on health.

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3. RISK POOLING AND INSURANCE COVERAGE • Between 1994/95 and 2007/08, the percentage of the population insured by the HIO increased

from 35 percent to 55 percent. However, it is important to note that in the same period the role of the HIO as a financing agent declined from 12 percent to 8 percent, while the share of out-of-pocket spending to total health spending rose from 51 percent to 60 percent.

• The last major expansion of health insurance in Egypt was the introduction of the School Health Insurance Program in the mid-1990s.

• Between 1994/95 and 2007/08, HIO expenditures rose 317 percent, from 870 million LE to 2,760 million LE. This increase is associated with an increase in the number of beneficiaries and a 60 percent increase in the expenditure per beneficiary. Expenditures for pensioners and widows increased by more than six times in the same period.

• The HIO continues to have gaps between revenues and expenditures, for several reasons: the HIO administers a fragmented set of social health insurance programs established under different laws covering different population groups with separate rules for payment of premiums and management of benefits, leading to inefficiencies; benefits packages are broad and generous and include inpatient care, plastic surgery, and treatment abroad, while contribution and copayment rates are low, employers are able to opt out, and beneficiaries in low-income regions bear a larger cost burden than those in high-income regions.

• Tunisia (99 percent), Iran (98 percent), and Jordan (83 percent) all have achieved near universal coverage through social health insurance. Egypt was a pioneer in the early 1960s but now lags behind its peers in extending risk pooling to its population.

4. USES OF FUNDS • In 2007/08, spending on pharmaceuticals and private clinics accounted for half of all health

spending in Egypt (25.9 percent and 23.8 percent, respectively).

• In 2007/08, MOH facilities accounted for only 21 percent of total spending in Egypt, a decline from 25 percent of total spending in 2001/02.

• Between 2001/02 and 2007/08, the share of expenditures at public facilities has remained constant.

• Between 2001/02 and 2007/08, the GOE significantly increased investments in tertiary care. In 2001/02, expenditure on MOH hospitals was 3.8 billion LE and on university hospitals 1.5 billion LE. In 2007/08, expenditures at university hospitals had increased to 3.5 billion LE and those at MOH hospitals had dropped to 2.9 billion LE. This shows an increased focus on private sector provision of outpatient curative care.

• Between 2001/02 and 2007/08, the MOH more than tripled its spending on primary health care. Spending went from 1.1 billion LE in 2001/02 to 3.66 billion LE in 2007/08. A surprising finding is that increased outlays in primary health care have been accompanied by increased out-of-pocket spending.

• Since 1994/95, when the first NHA was conducted, the private sector has remained the major provider of outpatient services in Egypt.

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5. DISCRETIONARY SPENDING ACCOUNT Ever since the 1990s, the government has had a special discretionary fund (the PTES) to pay for treatment abroad and for certain services within the country for people who cannot afford such services. Starting in 2001, the GOE significantly increased the nature and scope of this scheme. Today, over 1.75 million Egyptians, nearly 2.6 percent of the total population, benefit from the scheme. While there are policies and procedures for how these benefits can and should be accessed, recent developments indicate a possibility that this scheme is being misused.1 The rapid increase in PTES spending coincides with the rapid expansion of Specialized Centers under the MOH. According to the World Bank, these two factors have contributed to the “rapid increase in health spending among the government authorities.”2

Obtaining information on spending under PTES is extremely difficult due to a lack of transparency. However, it is estimated that PTES spending amounted to over 1.4 billion LE. Only 8.5 percent of the expenditures were incurred at private hospitals and another 2 percent on treatment abroad. The remaining expenditures were channeled to public facilities.

POLICY IMPLICATIONS OF NHA FINDINGS

The following observations represent actions that could be taken as a result of these findings.

• Increase public investments in health: There is an urgent need for Egypt to increase public investments in health overall and significantly increase its investments in the MOH.

• Address the issue of out-of-pocket spending: The continued high burden of out-of-pocket spending is a matter of serious concern. There is a need to understand why increased spending on primary health care as well as increase in insurance coverage has not led to a decrease in out-of-pocket spending.

• Fast-track comprehensive insurance reforms: There is a need to fast-track MOH efforts for comprehensive reforms of the health insurance systems. The increase in out-of-pocket spending, even as insurance coverage has expanded, signals the need to make social health insurance both responsive to consumer needs and sustainable in Egypt. The lack of efficiency in the current system that is due to fragmentation must be remedied by consolidating strategy and procedures into one system designed to cover the various population groups.

• Link investments to disease burden and demographic trends: Geographic or programmatic investments in health follow historical patterns and are tied to inputs (personnel, number of beds, etc.). Investments do not reflect the geographic distribution of disease burden (increased chronic diseases) or demographic trends (increased percentage of elderly). While such a change will continue to emphasize primary health care, it will lead to moving resources to high disease burden governorates, increased focus on prevention, and a focus on developing and implementing programs for the new population groups such as the elderly.

• Comprehensive pharmaceutical reforms: The MOH has undertaken various steps to streamline the procurement and distribution of pharmaceuticals. However, expenditures on pharmaceuticals remain high, with most spending incurred directly by households. Any attempt at reducing out-of-pocket spending and improving equity and efficiency of health spending has to include a continued emphasis on a comprehensive reform of the pharmaceutical sector.

1 In March, a series of articles was published in local newspapers criticizing the implementation of the scheme. This led to a stand-off between the Minister of Health, who wanted to reform the program, and the People’s Assembly, which did not want any restriction put on their ability to provide care for their constituents. 2 World Bank. January 2006. Egypt Health Policy Note: Egypt Health Expenditure Review. http://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2008/12/22/000333038_20081222033756/Rendered/INDEX/469380ESW0whit10Policy0Note010Final.txt

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• Make the private sector a true partner: The private sector remains the single largest provider of outpatient care. Similarly, there has been an expansion in the number and types of private hospitals in the country. However, the government has not effectively leveraged the private sector to meet the health needs of the population by increasing access to quality health care services. On the contrary, some government actions, such as channeling government and HIO funds primarily to public facilities, stifle the growth of private markets.

• Control and rationalize spending under PTES: The government initiated PTES as a safety net for those who did not have insurance coverage. However, as the analysis has shown, expenditures under this scheme have grown exponentially and there is very little transparency in how resources are being spent. There is a clear need to control and rationalize spending under PTES.

SUGGESTED IMPROVEMENTS TO THE HEALTH FINANCING SYSTEM WITHIN THE MOH

The following observations represent actions that could be taken as a result of these findings.

• Improve capacity in health policy and health economics at the MOH: The lack of technical capacity in health economics at the MOH Department of Planning is an obstacle to conducting health financing analyses (NHA, costing and efficiency studies, resource tracking, etc.). These analyses are needed to support the MOH’s effort to reform Egypt’s health system, including the major expansion of health insurance. While the Department of Planning has a Health Economics Unit, it is not operational. It lacks staff with necessary skills in health economics, health policy, statistics, management, and epidemiology.

• Institutionalize a structure to systematically collect and analyze information on financing and costs at the facility and program levels. Every round of NHA has highlighted the fact that the MOH cannot tell on a monthly basis what it spends by governorate, by hospital, by primary health care facility, or by program. This means that managers do not have the information to monitor and efficiently run their facilities and programs. Similarly, hospitals and primary health care centers do not have information on the cost and efficiency of services they produce. The MOH has undertaken an innovative expenditure tracking exercise to understand how family planning, maternal-child health, and infection control program expenditures are made by level (national, governorate, districts, and facilities), activity, and function. Similarly, costing exercises have been undertaken at a number of hospitals and primary health care centers. It is important to put a system in place whereby NHA, expenditure tracking, and costing become routine activities of the MOH and to ensure that this information is used for planning, budgeting, and policy formulation.

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1. NATIONAL HEALTH ACCOUNTS: MAIN FINDINGS

1.1 OVERVIEW Egypt has a pluralistic and fragmented health system with multiple sources of financing (see Annex A), financing agents (see Annex B), and providers (see Annex C). The multiple financing sources include government spending that comes from direct tax revenues, out-of-pocket spending by households as premium payments for insurance and direct spending on health, employers’ spending on the health of their employees, a dedicated cigarette tax, and donor assistance. There are a large number of entities through which these resources flow, including the Ministry of Health (MOH), the Ministry of Higher Education (MOHE), the Health Insurance Organization (HIO), other ministries, public sector entities, and nongovernmental organizations (NGOs). The provider market is equally fragmented; the MOH owns and operates a large network of hospitals and outpatient facilities. Other public sector entities, such as the HIO, the Curative Care Organization (CCO), and Universities and Teaching Hospitals and Institutes Organization (THIO), all run their own facilities. There is a growing private market composed of hospitals, outpatient clinics, pharmacies, and traditional healers. An important characteristic of health financing in Egypt is the fact that the flow of funds from sources to financing agents and then on to providers occurs along almost mutually exclusive tracts (silos). This makes it difficult to effectively coordinate and manage across ministries, sectors (public and private), and entities.

Table 1 provides a summary of the main findings of the National Health Accounts (NHA) for fiscal 2007/08. In that year, Egypt spent 42.5 billion Egyptian pounds (LE) on health care, representing 4.75 percent of the country’s gross domestic product (GDP). This translates to a per capita health spending of 566.4 LE. Household spending finances 60 percent of total health spending, followed by Ministry of Finance (MOF) spending at 35 percent, with the rest accounted for by public and private firms and external assistance. Spending on pharmaceuticals remains high, 26 percent of total health spending.

Between 1994/95 and 2001/02, total health spending rose from 7.5 billion LE to 42.5 billion LE. Public spending increased from 2.5 billion LE to 13.9 billion LE; of this, MOH expenditures rose from 1.6 billion LE to 10.2 billion LE. Prima-facie, these increases appear spectacular. However, a much more sobering picture emerges when these expenditures are viewed in the context of the country’s overall macroeconomic situation.

Between 1994/95 and 2001/02, the percentage of the country’s GDP going to health increased from 3.70 percent to 5.99 percent but has subsequently declined to 4.75 percent. Public spending on health as a percentage of total health spending has remained at 1994/95 levels, and government spending on health as a percentage of its budget has remained static at 5 percent. Between 1994/95 and 2007/08, MOH spending as a percentage of total health spending increased from 22 percent to 24 percent, representing an increase of just two percentage points.

The global experience has been that as a country’s per capita income rises, so does the share of public spending on health. At the same time, the burden of private spending on heath declines. This is not the case with Egypt – out-of-pocket spending as a percentage of total health spending has increased. Given the continued high burden of infectious diseases, the emergence of chronic health conditions as a public health concern, and the aging of the population, there is a need for the country to increase its investments in health.

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TABLE 1: SUMMARY OF THE MAIN NHA FINDINGS, 1994/95, 2001/02, 2007/08 1994/95 2001/02 2007/08

Total Population (Million) 59.2 66.7 75.1 GDP Estimates (LE Billion) 203.135 385.020 896.500 Total Health Expenditure (THE) (LE Billion) 7.516 23.081 42.539 Public Health Expenditures (LE Billion) 2.490 6.835 13.866 MOH Expenditures (LE Billion) 1.620 5.199 10.226 Household Expenditures (LE Billion) 3.819 14.294 25.507 Pharmaceuticals (LE Billion) 2.716 8.585 11.012 THE per Capita (LE) 126.959 346.042 566.431 Percent GDP Spent on Health 3.70% 5.99% 4.75% Public Health Expenditures Percent of THE 33% 30% 33% MOH Expenditures Percent of THE 22% 23% 24% Out-of-Pocket Expenditures as Percent of THE 51% 62% 60% Pharmaceuticals as Percent of THE 36% 37% 26% Public Expenditures as Percent of Government of Egypt Expenditures 5% 5% MOH Expenditures as Percent of Government of Egypt Expenditures 4% 3%

1.2 EGYPT IN COMPARISON WITH OTHER MIDDLE-INCOME COUNTRIES IN THE REGION

Table 2 presents information comparing Egypt with other middle-income countries in the Middle East and North Africa region. Egypt spends less of its GDP on health than most other countries in the region. Only Algeria, Libya, and Syria spend less on health as a percentage of GDP. Government spending as a percentage of total health spending is the lowest in Egypt, as is health spending by the government of Egypt (GOE) as a percentage of its total budget. Out-of-pocket spending as a percentage of total health spending is the highest in Egypt. In terms of per capita spending on health, only Syria and Djibouti spend less than Egypt. Therefore, in terms of health spending, Egypt does not compare favorably with other middle-income countries in the region. There is a need to increase both the percentage of GDP going to health as well as public investments in health.

TABLE 2: EGYPT IN COMPARISON WITH OTHER MIDDLE-INCOME COUNTRIES IN THE REGION, 2008

PERCENT GDP

SPENT ON HEALTH

GOVERNMENT SPENDING AS

THE PERCENTAGE

HEALTH SPENDING AS PERCENTAGE

OF TOTAL GOVERNMENT

BUDGET

OUT-OF-POCKET

EXPENDITURE AS THE

PERCENTAGE

PER CAPITA HEALTH

SPENDING (CONSTANT

2005 US$)

Algeria 4.49% 83.85% 10.65% 15.30% 205 Djibouti 8.54% 76.07% 14.15% 23.60% 81 Egypt 4.75% 33.00% 5.00% 60.00% 111 Iran 6.30% 45.72% 11.40% 51.68% 294 Jordan 9.10% 62.20% 11.35% 33.40% 273 Lebanon 8.76% 48.99% 12.39% 39.95% 551 Libya 2.80% 75.88% 5.38% 24.12% 383 Morocco 5.33% 34.97% 6.17% 56.13% 133 Syria 3.23% 45.13% 6.01% 54.87% 76 Tunisia 5.95% 49.57% 8.90% 42.52% 213 Sources: World Health Organization (WHO) NHA data, Egypt NHA results, Jordan NHA report

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2. FLOW OF FUNDS

2.1 FINANCING SOURCES: WHO PAYS FOR HEALTH CARE?

As shown in Table 3 and Figure 1, in 2007/08, the greatest contributor to health financing in Egypt is household out-of-pocket spending, at 60 percent of total health spending. The MOF contributes only 35.3 percent, which translates to 201 LE per capita.

TABLE 3: FINANCING SOURCES OF THE EGYPTIAN HEALTH CARE SYSTEM, 2007/08

SOURCES AMOUNT (LE) PERCENT PER CAPITA Ministry of Finance 15,102,740,752 35.5% 201.11 Public Firms Funds 718,253,286 1.7% 9.56 Employer Funds (Private) 944,218,992 2.2% 12.57 Household Funds 25,507,964,370 60.0% 339.67 Donors 266,133,922 0.6% 3.54 Total 42,539,311,323 100% 566.46

Figure 1 also shows that, between 1994/95 and 2007/08, the donors’ share of total health spending declined from 2.9 percent to 0.6 percent, out-of-pocket spending increased from 51.0 percent to 60.0 percent, and the contribution of public firms declined from 11.4 percent to 1.7 percent.

FIGURE 1: FINANCING SOURCES OF THE EGYPTIAN HEALTH CARE SYSTEM, 1994/95, 2001/02, 2007/08

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2.2 FINANCING AGENTS: WHO MANAGES HEALTH FUNDS?

Financing agents are the institutions or entities that channel the funds received from financing sources and use these funds to pay for or purchase health services and activities. Table 4 and Figure 2 show that 57 percent of the funds in the Egyptian health system are managed through households’ out-of-pocket expenditures. The second major manager is the MOH, at 23 percent. The Ministry of Defense (MOD) and MOHE also play a significant role in the Egyptian health system, together managing almost 8 percent of funds. There are also minor financing agents, managing less than 6 percent (CCO, THIO, firms, and syndicates).

TABLE 4: FINANCING AGENTS OF THE EGYPTIAN HEALTH SYSTEM, 2007/08

FINANCING AGENT VALUE (LE) PERCENT PER CAPITA (LE) MOH 9,696,512,715 22.79 129.12 HIO 3,427,461,731 8.06% 45.64 CCO 206,522,627 0.49% 2.75 THIO 529,957,479 1.25% 7.06 MOHE 2,715,019,644 6.38% 36.15 MOD 500,000,000 1.18% 6.66 Other Govt. Orgs 218,079,931 0.51% 2.90 Public Firms 580,746,930 1.37% 7.73 Private Firms 262,514,457 0.62% 3.50 Household Out-of-Pocket 24,329,113,741 57.19% 323.97 Syndicates 73,382,068 0.17% 0.98 Total 42,539,311,323 100.00% 566.46

FIGURE 2: FINANCING AGENTS OF THE EGYPTIAN HEALTH SYSTEM, 2007/08

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2.3 PROVIDERS OF HEALTH CARE As shown in Table 5 and Figure 3, expenditures at private facilities (hospitals and clinics) and pharmacies, 31 percent and 26 percent respectively, account for half of all health spending in Egypt. MOH facilities represent 18 percent, followed by university hospitals at 8 percent and HIO facilities at about 6 percent.

TABLE 5: EXPENDITURE BY TYPE OF PROVIDER AND OWNERSHIP, 2007/08

PROVIDERS AMOUNT (LE) PERCENT PER CAPITA MOH Facilities 7,513,250,114 17.7% 100.05 CCO Hospitals 283,292,347 0.7% 3.77 THIO Hospitals 505,562,558 1.2% 6.73 University Hospitals 3,417,477,947 8.0% 45.51 Other Ministries’ Hospitals 220,117,840 0.5% 2.93 MOD Hospitals 522,630,000 1.2% 6.96 Ambulance Services 732,835,000 1.7% 9.76 HIO Facilities 2,441,294,977 5.7% 32.51 Private Hospitals 2,900,397,771 6.8% 38.62 Private Clinics 10,107,977,487 23.8% 134.60 Pharmacies 11,012,310,074 25.9% 146.64 Providers of Optical & Medical Goods 264,018,296 0.6% 3.52 Diagnostic Laboratories 78,530,505 0.2% 1.05 Blood Bank 5,525,000 0.0% 0.07 Rest of the World 33,134,621 0.1% 0.44 Others 1,109,109,250 2.6% 14.77 Govt Administration of Health 1,391,847,535 3.3% 18.53 Total 42,539,311,323 100.0% 566.46

FIGURE 3: EXPENDITURE BY TYPE OF PROVIDER AND OWNERSHIP, 2007/08

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2.4 EXPENDITURES AT A SUB-SYSTEM LEVEL

2.4.1 MINISTRY OF HEALTH

2.4.1.1. MOH EXPENDITURE FROM 2001 TO 2007 Table 6 and Figure 4 show that the MOH share of both the GOE budget and GOE expenditures has remained low, between about 3 percent and 4 percent, from 2001/02 to 2007/08.

TABLE 6: MOH BUDGET AND EXPENDITURE IN RELATION TO GOE BUDGET AND EXPENDITURE, 2001/02-2007/08

2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08

GOE Budget 126,853 141,000 159,600 177,427 214,672 274,169 269,618 GOE Exp. 134,403 149,315 164,884 179,813 236,280 251,060 293,708 MOH Budget 4,572 5,654 5,838 6,283 6,709 6,929 9,449 MOH Exp. 5,199 5,570 6,075 6,931 7,535 7,946 10,367 MOH as % GOE Budget 3.6% 4.0% 3.7% 3.5% 3.1% 2.5% 3.5% MOH as % GOE Exp 3.9% 3.7% 3.7% 3.9% 3.2% 3.2% 3.5% GDP Value 385,020 417,500 485,000 538,500 617,700 744,800 896,500 GOE Exp. as % GDP 34.9% 35.8% 34% 33.4% 38.3% 33.7% 32.8% MOH Exp. as % GDP 1.4% 1.3% 1.3% 1.3% 1.2% 1.1% 1.2%

FIGURE 4: MOH BUDGET AND EXPENDITURE SHARE OF THE GOE BUDGET AND EXPENDITURE, 2001/02–2007/08

As was seen above in Table 2, among all middle-income countries in the region, Egypt spends the lowest proportion of its budget on health. In addition, the MOH expenditure on average represents only 1 percent of the total GDP and one-fifth of the Egypt’s total health spending.

2.4.1.2 TRENDS IN MOH EXPENDITURE The MOH has moved toward increasing its central expenditures; as Figure 5 illustrates, expenditures by the MOH headquarters (HQ) have risen from 20 percent in 1994/95 to 52 percent in 2007/08. During the same time period, regional expenditures decreased from 80 percent to 48 percent.

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FIGURE 5: MOH TRENDS OF EXPENDITURE, 1994/95, 2001/01, 2007/08

2.4.1.3 MOH SOURCES OF FUNDS Table 7 shows that 93 percent of MOH activity is funded by the MOF, followed by self-funding at 4 percent. Funding from donors represents only 3 percent of MOH sources of funding.

TABLE 7: MOH SOURCES OF FUNDS, 2007/08

SOURCE HQ REGIONS TOTAL PERCENT

MOF 4,245,867,166 4,167,275,490 8,413,142,656 93%

Self Funds 192,945,029 144,760,523 337,705,552 4%

Donors 250,803,050 250,803,050 3%

TOTAL 4,689,615,245 4,312,036,013 9,001,651,258 100%

2.4.1.4 USES OF MOH FUNDS As shown in Table 8, 20.2 percent of MOH funds go to MOH hospitals, followed by Family Planning Centers (17.5 percent) and MOH Health Centers (14.6 percent). The MOH spends 11.5 percent on pharmacies and 15.4 percent on health care system administration.

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TABLE 8: USES OF MOH FUNDS, 2007/08

USE HQ REGIONS TOTAL PERCENT

MOH Hospitals 490,766,711 1,331,230,243 1,821,996,954 20.2%

HIO Hospitals 25,707,537 -- 25,707,537 0.3%

University Hospitals 225,355,326 -- 225,355,326 2.5%

THIO Hospitals 94,444,079 -- 94,444,079 1.0%

CCO Hospitals 43,080,102 -- 43,080,102 0.5%

MOD Hospitals 20,000,000 20,000,000 0.2%

MOH Specialized Hospitals 459,603,802 459,603,802 5.1%

Private Hospitals 126,736,530 126,736,530 1.4%

Family Planning Centers 14,191,000 1,561,827,661 1,576,018,661 17.5%

Ambulance Services 732,835,000 732,835,000 8.1%

Blood and Organ Banks 5,525,000 5,525,000 0.1%

Pharmacies 453,866,325 583,099,758 1,036,966,083 11.5%

Other Providers of Medical Goods 104,773,142 104,773,142 1.2%

Gov. Administration of Health 1,099,741,691 287,128,092 1,386,869,783 15.4%

Rest of the World 28,060,000 28,060,000 0.3% Total 4,689,615,245 4,312,036,013 9,001,651,258 100%

2.4.2 SPECIALIZED CENTERS OF EXCELLENCE

As illustrated in Figure 6, the MOF is the main source of funding for the Specialized Centers of Excellence, at 88.2 percent. This is followed by self-funding, at 11.4 percent. Donors, at only 0.4 percent, are a minor source of funding.

FIGURE 6: SPECIALIZED CENTERS OF EXCELLENCE SOURCES OF FUNDS, 2007/08

Table 9 shows that 64 percent of funds for Specialized Centers of Excellence is used for MOH Specialized Hospitals and 36 percent is used for pharmaceuticals.

TABLE 9: USES OF SPECIALIZED CENTERS OF EXCELLENCE FUNDS, 2007/08

USE VALUE IN LE PERCENT MOH Specialized Hospitals 441,856,469 64% Pharmacies 253,004,988 36% Total 694,861,457 100%

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2.4.3 HEALTH INSURANCE ORGANIZATION

Students, who are covered by Law 99, represent the highest percentage (43 percent) of HIO beneficiaries (see Figure 7). The next largest group is infants, covered by Decree 380; they represent 30 percent of HIO beneficiaries. Twenty-one percent of HIO beneficiaries are workers covered by both Laws 32 and 79. Pensioners and widows (included in Laws 32 and 79) comprise 6 percent of HIO beneficiaries.

FIGURE 7: HIO BENEFICIARIES, BY INSURANCE LAW, 2007/08

Figure 8 shows how the percentage of the population insured by the HIO has grown, from 35 percent in 1994/95 to 55 percent in 2007/08.

FIGURE 8: PERCENTAGE OF POPULATION INSURED BY HIO, 1994/95-2007/08

The HIO depends on premiums and insured copayments as its main source of finance. Figure 9 illustrates that these sources together represent 55 percent of the HIO’s total revenue. Earnings from the HIO as a provider for other organizations represent 27 percent of revenue and MOH allocations to the HIO represent 18 percent of its funds.

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FIGURE 9: HIO SOURCES OF FUNDS, 2007/08

As shown in Table 10, the HIO uses its funds primarily to finance its hospitals (56.1 percent of HIO funding) followed by pharmaceuticals, at 19.1 percent. The HIO also purchases health care services on behalf of its beneficiaries from non-HIO facilities: MOH hospitals (4.8 percent), dialysis centers (3.4 percent), university hospitals (3.1 percent), and private hospitals (2.0 percent).

TABLE 10: HIO USES OF FUNDS, 2007/08

USE AMOUNT (LE) PERCENT MOH Hospitals 166,000,000 4.8% HIO Hospitals 1,923,967,351 56.1% University Hospitals 107,440,000 3.1% THIO Hospitals 42,080,000 1.2% CCO Hospitals 43,140,000 1.3% MOD Hospitals 2,630,000 0.1% Private Hospitals 67,960,000 2.0% Dialysis Centers 117,630,000 3.4% MOH Health Centers 1,510,000 0.0% Other Health Centers 94,800,000 2.8% Medical and Diagnostic Laboratories 47,610,000 1.4% Pharmacies 655,979,468 19.1% Other Providers of Medical Goods 156,714,912 4.6% Total 3,427,461,731 --

As shown in Table 11, total HIO expenditure doubled between 1994/95 and 2001/02, going from 870 million LE to 1,715 million LE. It grew by another 60 percent by 2007/08, reaching 2,760 million LE. This increase is associated with an increase in the number of beneficiaries and a 60 percent increase in the expenditure per beneficiary from 1994 to 2007. It is remarkable that the expenditure covering pensioners and widows has increased by more than six times in the same period, going from 121 million LE in 1994/95 to 775 million LE in 2007/08.

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TABLE 11: HIO EXPENDITURE BY LAW, 1994/95, 2001/02, 2007/08 (MILLION LE)

EXPENDITURE, BY LAW TOTAL EXPEN-DITURE

NO. OF BENEFICI-

ARIES

EXPENDITURE/ BENEFICIARY LAW

79 PENSIONERS/

WIDOWS LAW

32 LAW

99 DECR-EE 380

1994/95 240 121 219 290 -- 870 20,670 4,209 2001/02 391 334 304 598 88 1,715 30,633 5,599 2007/08 583 775 501 752 149 2,760 41,073 6,720

Of the 11 middle-income countries in WHO’s Eastern Mediterranean region (EMR), eight have less than 10 percent of the private expenditure on health covered by private prepaid plans. Egypt is at the low end of that group, at 0.2 percent, as shown in Figure 10.

FIGURE 10: PRIVATE PREPAID PLANS AS A PERCENT OF PRIVATE EXPENDITURE ON HEALTH, 2007/08

Private prepaid plans as % of private expenditure on healthEMR Middle-income Countries, 2008 (World Bank)

14.0 13.7

3.80.00.00.00.20.3

5.16.9

17.3

0.05.0

10.015.020.0

LebanonTunisia

MoroccoJordan

Algeria

Iran (Islamic Republic o

f)

PakistanEgypt

Libyan Arab Jamahiriya Iraq

Syrian Arab Republic

Source: World Bank

2.4.4 CURATIVE CARE ORGANIZATION

Figure 11 shows that an appreciable share – nearly one half – of CCO revenue is from private firms (36.4 percent) and public firms (10.3 percent). Revenues from other institutes and individuals in the form of self funds is at 27.3 percent. MOH allocations to the CCO represent 26.0 percent of its funds.

FIGURE 11: CCO SOURCES OF FUNDS, 2007/08

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As shown in Table 12, the CCO uses most of its funds (95 percent) to finance its hospitals, followed by funding for pharmaceuticals (3 percent). The CCO uses only 2 percent of it sources for its administration.

TABLE 12: CCO USES OF FUNDS, 2007/08

Use Value (LE) Percent CCO Hospitals 195,699,043 95% Pharmacies 5,845,832 3% Administration 4,977,752 2% Total 206,522,627 --

2.4.5 TEACHING HOSPITALS AND INSTITUTES ORGANIZATION

As illustrated in Figure 12, the THIO depends mainly on MOH fund allocations for the largest share of its resources (70.8 percent). Its second source of funding (29.0 percent) comes from providing health care services to institutes and individuals. The donors’ share is very minor, 0.2 percent.

FIGURE 12: THIO SOURCES OF FUNDS, 2007/08

The THIO uses 69 percent of its funds to finance its hospitals and the remaining 31 percent for pharmaceuticals, as shown in Table 13.

TABLE 13: THIO USES OF FUNDS, 2007/08

Use Value (LE) Percent THIO Hospitals 367,738,479 69% Pharmacies 162,219,000 31% Total 529,957,479 100%

2.4.6 MINISTRY OF HIGHER EDUCATION HOSPITALS

As illustrated in Figure 13, MOF allocations are the main source of funding for MOHE hospitals (72 percent). The second source of funding (27.6 percent) is revenues from providing health care services to institutes and individuals. The donors’ contribution to funding of MOHE hospitals is 0.4 percent.

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FIGURE 13: MOHE HOSPITALS SOURCES OF FUNDS, 2007/08

The MOHE uses 87 percent of its funds to finance its university hospitals. Thirteen percent is used for pharmaceuticals, as indicated in Table 14.

TABLE 14: MOHE HOSPITALS USES OF FUNDS, 2007/08

USE VALUE (LE) PERCENT University Hospitals 2,364,176,644 87% Pharmacies 350,843,000 13% Total 2,715,019,644 --

2.4.7 PUBLIC AND PRIVATE FIRMS

This section covers the sources and uses of funds by public and private firms. The data used in this section are not comprehensive due to the time constraints for data collection. This section is supplementary and not the main focus of NHA 2007/08.

2.4.7.1 PUBLIC FIRMS As illustrated in Table 15, public firms depend mainly on self-funding, which represents 97 percent of their total funding, followed by premiums and contributions, which represent only 3 percent. Sixty-six percent of public firms participate in an insurance program for their employees while 34 percent contract directly with health care providers. Sixty-eight percent of public firm funds go to private hospitals, followed by 10 percent going to pharmacies and 7 percent going to other health centers. The MOH and medical diagnostic labs each represent 4 percent of the public firms’ uses of funds.

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TABLE 15: PUBLIC FIRMS SOURCES AND USES OF FUNDS, 2007/08

PUBLIC FIRMS SOURCE OF FUNDS (LE)

OFFERING INSURANCE PROGRAM

NOT OFFERING

INSURANCE PROGRAM

TOTAL PERCENT

Firm 364,321,612 197,327,818 561,649,430 97% Premiums & Contributions 19,097,500 19,097,500 3% Total 383,419,112 197,327,818 580,746,930 100% Percentage 66% 34% 100%

USES OF PUBLIC FIRMS FUNDS (LE)

OFFERING INSURANCE PROGRAM

NOT OFFERING

INSURANCE

TOTAL PERCENT

MOH Hospitals 3,844,774 20,833,831 24,678,605 4.2% HIO Hospitals -- 13,518,856 13,518,856 2.3% University Hospitals -- -- -- 0.0% THIO Hospitals -- -- -- 0.0% CCO Hospitals -- 935,000 935,000 0.2% Other Ministries’ Hospitals -- 950,000 950,000 0.2% Private Hospitals 286,382,863 108,600,634 394,983,497 68.0% Offices of Physicians 1,845,285 8,974,498 10,819,783 1.9% Offices of Dentists 341,199 32,000 373,199 0.1% MOH Health Centers -- 105,600 105,600 0.0% Other Health Centers 41,000,000 41,000,000 7.1% Medical and Diagnostic Laboratories 13,911,555 10,064,435 23,975,990 4.1% Pharmacies 27,432,006 28,746,146 56,178,152 9.7% Providers of Optical Glasses -- -- -- 0.0% Other providers of Medical Goods -- 839,356 839,356 0.1% Rest of the World 1,591,211 1,900,000 3,491,211 0.6% Others 7,070,219 1,827,462 8,897,681 1.5% 383,419,112 197,327,818 580,746,930 100.0%

2.4.7.2 PRIVATE FIRMS As Table 16 illustrates, private firms depend solely (100 percent) on self-funding. Fifty-seven percent of public firms participate in an insurance program for their employees. The remaining 43 percent either provide services directly or through contracting with health care providers. Fifty-four percent of the private firms’ funds go to private hospitals, 14 percent to private clinics/physicians’ offices, and 8 percent to pharmacies.

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TABLE 16: PRIVATE FIRMS SOURCES AND USES OF FUNDS, 2007/08

PRIVATE FIRMS SOURCE OF FUNDS (LE)

OFFERING

INSURANCE PROGRAM

NOT OFFERING

INSURANCE OG

TOTAL PERCENT

Firm 149,522,947 112,991,510 262,514,457 100% Premiums & Contributions -- -- - -- Total 149,522,947 112,991,510 262,514,457 100% Percentage 57% 43% 100%

USES OF PRIVATEFIRMS FUNDS (LE)

OFFERING

INSURANCE PROGRAM

NOT OFFERING

INSURANCE PROGRAM

TOTAL PERCENT

MOH Hospitals 850,000 2,406,120 3,256,120 1.2% HIO Hospitals -- -- -- 0.0% University Hospitals -- 1,150,000 1,150,000 0.4% THIO Hospitals -- 1,300,000 1,300,000 0.5% CCO Hospitals -- 438,202 438,202 0.2% Other Ministries’ Hospitals 200,000 -- 200,000 0.1% Private Hospitals 77,047,799 64,466,320 141,514,119 53.9% Offices of Physicians 31,675,171 5,697,174 37,372,345 14.2% Dentists’ Offices 867,044 200,000 1,067,044 0.4% MOH Health Centers -- -- -- 0.0% Other Health Centers -- 95,489 95,489 0.0% Medical and Diagnostic Laboratories 722,582 6,221,933 6,944,515 2.6% Pharmacies 4,401,942 17,295,594 21,697,536 8.3% Providers of Optical Glasses 60,000 -- 60,000 0.0% Other Providers of Medical Goods 12,000 1,618,886 1,630,886 0.6% Rest of the World -- 1,583,410 1,583,410 0.6% Others 33,686,409 10,518,382 44,204,791 16.8% 149,522,947 112,991,510 262,514,457 100.0%

2.4.7.3 TOTAL FIRMS As shown in Table 17, firms depend mainly (98 percent) on self-funding, followed by premiums and contributions, which represent only 2 percent. Sixty-three percent of firms participate in an insurance program for their employees, while 43 percent either directly provide health care services or contract directly with other providers.

Firms spend 64 percent of their resources on private hospitals, whether through insurance programs or direct contracts. This is followed by pharmacies, which receive 9 percent of firm funding through insurance programs (3.8 million LE) or directly purchased (46 million LE). Physicians’ clinics consume 6 percent of funds, through insurance programs (33.5 million LE) or direct contracts (14.7 million LE).

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TABLE 17: PUBLIC AND PRIVATE FIRMS SOURCES AND USES OF FUNDS, 2007/08

PUBLIC AND PRIVATE FIRMS SOURCE OF FUNDS (LE)

OFFERING

INSURANCE PROGRAM

NOT OFFERING

INSURANCE PROGRAM

TOTAL PERCENT

Firm 513,844,559 112,991,510 824,163,887 98% Premiums & Contributions 19,097,500 -- 19,097,500 2% Total 532,942,059 112,991,510 843,261,387 100% Percentage 63% 43%

USES OF PUBLIC AND PRIVATE FIRMS FUNDS (LE)

OFFERING

INSURANCE PROGRAM

NOT OFFERING

INSURANCE

TOTAL PERCENT

MOH Hospitals 4,694,774 23,239,951 27,934,725 3% HIO Hospitals - 13,518,856 13,518,856 2% University Hospitals - 1,150,000 1,150,000 0% THIO Hospitals - 1,300,000 1,300,000 0% CCO Hospitals - 1,373,202 1,373,202 0% Other Ministries’ Hospitals 200,000 950,000 1,150,000 0% Private Hospitals 363,430,662 173,066,954 536,497,616 64% Offices of Physicians 33,520,456 14,671,672 48,192,128 6% Offices of Dentists 1,208,243 232,000 1,440,243 0% MOH Health Centers -- 105,600 105,600 0% Other Health Centers 41,000,000 95,489 41,095,489 5% Medical and Diagnostic Laboratories 14,634,137 16,286,368 30,920,505 4% Pharmacies 31,833,948 46,041,740 77,875,688 9% Providers of Optical Glasses 60,000 -- 60,000 0% Other Providers of Medical Goods 12,000 2,458,242 2,470,242 0% Rest of the World 1,591,211 3,483,410 5,074,621 1% Others 40,756,628 12,345,844 53,102,472 6% 532,942,059 310,319,328 843,261,387 100%

2.5 SPECIAL TREATMENT FUND Since the 1990s, the GOE has had a special discretionary fund (PTES) to pay for treatment abroad and for certain services delivered within the country for those who could not otherwise afford to access the services. Starting in 2001, the government significantly increased the nature and scope of this scheme. Today, over 1.75 million Egyptians, 2.6 percent of the total population, benefit from this scheme. While there are policies and procedures in place on how these benefits can and should be accessed, recent developments indicate a possibility that this scheme is being misused.3

3 In March, a series of articles was published in local newspapers criticizing the implementation of the scheme. This led to a stand-off between the Minister of Health, who wanted to reform the program, and the People’s Assembly, which did not want any restriction put on their ability to provide care for their constituents.

The rapid increase in PTES spending coincides with the rapid expansion of Specialized Centers under the

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MOH. According to the World Bank, these two factors have contributed to the “rapid increase in health spending among the government authorities.”4

Obtaining information on spending under PTES is extremely difficult due to a lack of transparency. However, it is estimated that spending amounted to over 1.4 billion LE. Only 8.5 percent of the expenditures were incurred at private hospitals and another 2 percent on treatment abroad. The remaining expenditures were channeled to public facilities.

Table 18 demonstrates that the number of beneficiaries of the special treatment decrees increased steadily and significantly – by 4,565 percent – between 1994 and 2008. This demonstrates an increasing need for the special treatment decrees for accessing the health care services.

TABLE 18: NUMBER OF BENEFICIARIES OF THE SPECIAL TREATMENT DECREES, 2007/08

YEAR LOCAL ABROAD TOTAL PERCENT INCREASE

1994 38,547 312 38,859 -- 1995 62,121 392 62,513 61% 2001 751,949 175 752,124 1,103% 2002 1,069,459 50 1,069,509 42% 2007 1,601,613 83 1,601,696 50% 2008 1,759,815 79 1,759,894 10%

Figure 14 shows the increase in the percentage of special treatment beneficiaries in the population, which grew from .07 percent in 1994 to 2.59 percent in 2008.

FIGURE 14: SPECIAL TREATMENT BENEFICIARIES AS A PERCENTAGE OF THE POPULATION, 2007/08

As shown in Table 19, 63 percent of the PTES fund was used to finance MOH hospitals. University hospitals received 15 percent, private hospitals received 9 percent, and CCO hospitals received 3 percent.

4 World Bank. January 2006. Egypt Health Policy Note: Egypt Health Expenditure Review. http://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2008/12/22/000333038_20081222033756/Rendered/INDEX/469380ESW0whit10Policy0Note010Final.txt

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TABLE 19: USES PTES OF FUNDS, 2007/08

TREATMENT EXPENDITURES AMOUNT (LE) PERCENT

MOH Hospitals 937,150,592 62.77% University Hospitals 225,355,326 15.09% Private Hospitals 126,736,530 8.49% CCO Hospitals 43,080,102 2.89% HIO Hospitals 25,707,537 1.72% Military Hospitals 20,000,000 1.34% Abroad 28,060,000 1.88% Vacsera (vaccine producer and blood bank) 6,626,292 0.44% Liver (intervention) 62,950,243 4.22% Prosthesis 17,393,378 1.16% Total 1,493,060,000

2.6 HOUSEHOLDS Out-of-pocket spending represents 60 percent of total health spending in Egypt and accounts for the management of approximately 57 percent of the funds. As shown in Table 22 and Figure 15, private clinics consume the greatest share (38.4 percent) of household out-of-pocket expenditures on health, followed by pharmacies, at 33.1 percent. For hospitalization services, private hospitals receive the chief share, 8.2 percent, followed by MOH hospitals at 3.5 percent.

TABLE 20: OUT-OF-POCKET EXPENDITURE BY PROVIDER, 2007/08

OUT-OF-POCKET EXPENDITURES VALUE IN L.E PERCENT PER CAPITA

Private Hospitals 2,095,869,057 8.2% 27.91 Private Clinics 9,796,647,822 38.4% 130.45 MOH Hospitals 882,804,930 3.5% 11.76 University Hospitals 719,355,977 2.8% 9.58 HIO Hospitals 478,101,233 1.9% 6.37 Other Public Hospitals 218,967,840 0.9% 2.92 MOH Health Centers 749,217,191 2.9% 9.98 Pharmaceuticals 8,445,711,515 33.1% 112.46 Other Exp. 2,121,288,804 8.3% 28.25 Total 25,507,964,370 100% 339.67

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FIGURE 15: HEALTH CARE PROVIDERS’ SHARE OF OUT-OF-POCKET EXPENDITURE, 2007/08

2.7 HEALTH SPENDING SILOS Table 21 demonstrates the parallel streams (silos) of revenue flows from financing agents to providers. This is an important characteristic of the Egyptian health system. Public spending goes primarily to public providers and private spending to private providers. The MOH spends very little on other public providers including the HIO and university facilities. The HIO in turn spends largely on its own facilities. What this means is that the government does not view the private sector as a true partner in increasing access to health services. Public spending, whether at the MOH, HIO, or university hospitals, is not linked to performance but rather based on historical budgets, the number of personnel employed, and the infrastructure (number of beds). If the government desires to exploit the potential of the entire health care system to improve access, reduce inequities, and improve efficiency, there is a need to reconfigure the payer-provider relationship.

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TABLE 21: THE PAYER-PROVIDER SILO, 2007/08

CATEGORIES MOH HIO HOUSEHOLDS MOH Hospitals 17.4% 4.8% 3.5% HIO Hospitals 0.2% 56.1% 1.9% University Hospitals 2.2% 3.1% 2.8% THIO Hospitals 4.4% 1.2% 0.0% CCO Hospitals 0.4% 1.3% 0.0% MOD Hospitals 0.2% 0.1% 0.0% MOH Specialized Hospitals 9.3% 0.1% 0.0% Private Hospitals 1.2% 2.0% 8.2% Family Planning Centers 15.1% 0.0% 0.0% Dialysis Centers 0.0% 3.4% 0.0% MOH Health Centers 12.6% 0.0% 2.9% Other Health Centers 0.1% 2.8% 0.0% Private Clinics 0.0% 0.0% 38.4% Medical and Diagnostic Labs 0.0% 1.4% 0.0% Ambulance Services 7.0% 0.0% 0.0% Blood and Organ Banks 0.1% 0.0% 0.0% Pharmacies 14.1% 19.1% 33.1% Other Providers of Medical Goods 1.0% 4.6% 0.0% Government Administration of Health 13.3% 0.0% 0.0% Rest of the World 0.3% 0.0% 0.0% Others 1.1% 0.0% 9.2% Total 100.0% 100.0% 100.0%

Source: World Bank

2.8 STUDY LIMITATIONS This third round of NHA in Egypt responds to the MOH’s need to understand the status of the country’s health spending. It uses available data. As such, this round did not cover all sectors (i.e. NGOs), and it used estimates for household spending. The lack of costing data means that it was not possible to estimate expenditures by types of service and functions. An extensive costing study is being undertaken and a Household Health Care Utilization and Expenditure survey is currently being conducted by the Central Agency for Public Mobilization and Statistics (CAPMAS). The next round of NHA (for fiscal 2008/09), to be completed by October 2010, will be more rigorous and comprehensive. However, even with these limitations, a number of key findings emerge that have policy implications.

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3. POLICY IMPLICATIONS OF NHA FINDINGS

The following observations represent possible actions that could be taken as a result of these findings.

Increase public investments in health: There is an urgent need for Egypt to increase public investments in health overall and significantly increase its investments in the MOH.

The MOH has moved toward increasing its central expenditures, expenditures by the MOH headquarters (HQ) have risen from 20 percent in 1994/95 to 52 percent in 2007/08. During the same time period, regional expenditures decreased from 80 percent to 48 percent.

Address the issue of out-of-pocket spending: The continued high burden of out-of-pocket spending is a matter of serious concern. There is a need to understand why increased spending on primary health care as well as increase in insurance coverage has not led to a decrease in out-of-pocket spending.

Fast-track comprehensive insurance reforms: There is a need to fast-track MOH efforts for comprehensive reforms of the health insurance systems. The increase in out-of-pocket spending, even as insurance coverage has expanded, signals the need to make social health insurance both responsive to consumer needs and sustainable in Egypt. The lack of efficiency in the current system that is due to fragmentation must be remedied by consolidating strategy and procedures into one system designed to cover the various population groups.

Link investments to disease burden and demographic trends: Geographic or programmatic investments in health follow historical patterns and are tied to inputs (personnel, number of beds, etc.). Investments do not reflect the geographic distribution of disease burden (increased chronic diseases) or demographic trends (increased percentage of elderly). While such a change will continue to emphasize primary health care, it will lead to moving resources to high disease burden governorates, increased focus on prevention, and a focus on developing and implementing programs for the new population groups such as the elderly.

Implement comprehensive pharmaceutical reforms: The MOH has taken steps to streamline the procurement and distribution of pharmaceuticals. However, these expenditures remain high, with most spending incurred directly by households. Any attempt at reducing out-of-pocket spending and improving equity and efficiency of health spending has to include a continued emphasis on a comprehensive reform of the pharmaceutical sector.

Make the private sector a true partner: The private sector remains the single largest provider of outpatient care in Egypt. Similarly, there has been an expansion in the number and types of private hospitals in the country. However, the government has not effectively leveraged the private sector to meet the health needs of the population by increasing access to quality health care services. On the contrary, some government actions, such as channeling government and HIO funds primarily to public facilities, stifle the growth of private markets.

Control and rationalize spending under PTES: The government initiated PTES as a safety net for those who did not have insurance coverage. However, as the analysis has shown, expenditures

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under this scheme have grown exponentially and there is very little transparency regarding how resources are being spent. There is a clear need to control and rationalize spending under PTES.

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4. SUGGESTED IMPROVEMENTS TO THE HEALTH FINANCING SYSTEM WITHIN THE MINISTRY OF HEALTH

The following observations represent possible actions that could be taken as a result of these findings.

• Improve capacity in health policy and health economics at the MOH: The lack of technical capacity in health economics at the MOH Department of Planning is an obstacle to conducting the health financing analyses (NHA, costing and efficiency studies, resource tracking, etc.). These types of analyses are needed to support the MOH’s effort to reform the health system in Egypt, including the major expansion of health insurance. While the Department of Planning has a Health Economics Unit, it is not operational. The unit lacks the staff with the necessary skills in health economics, health policy, statistics, management, and epidemiology.

• Institutionalize a structure to systematically collect and analyze information on financing and costs at the facility and program levels. Every round of NHA has highlighted the fact that the MOH cannot tell on a monthly basis what it spends by governorate, by hospital, by primary health care facility, or by program. This means managers do not have the information to monitor and efficiently run their facilities and programs. Similarly, hospitals and primary health care centers do not have information on the cost and efficiency of services they produce. The MOH has undertaken an innovative expenditure tracking exercise to understand how family planning, maternal-child health, and infection control program expenditures are made, by level (national, governorate, districts, and facilities), activities, and functions. Similarly, costing exercises have been undertaken at a number of hospitals and primary health care centers. It is important to put a system in place whereby NHA, expenditure tracking, and costing become routine activities of the MOH and to ensure that this information is used for planning, budgeting, and policy formulation.

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ANNEX A: TABLE ES-1 OVERVIEW OF EGYPTIAN HEALTH SECTOR

BENEFITS BY HEALTH

SUBSYSTEMS

COVERAGE/ SPECIAL

CATEGORIES

PRINCIPAL FINANCING

SOURCES

PROVIDER–PAYER

RELATIONSHIP

PERCENTAGE OF

POPULATION COVERED OR

ELIGIBLE

SIZE OF OPERATION

Describes types of services and benefits available

Describes coverage and eligibility criteria, special programs for specific population groups

Describes main sources of financing

Describes relationship between financing and service delivery functions

No. of people covered or eligible by health system nationwide

As indicated by staff, beds, or number of facilities

GOVERNMENT(PUBLIC) SECTOR

MINISTRY OF HEALTH (MOH) MOH facilities provide comprehensive public health services and preventive and curative care services at the primary, secondary, and tertiary levels

Coverage: all citizens and residents Highly subsidized care services for the entire population

Ministry of Finance (MOF) (general tax revenues) Household spending (out-of-pocket [OOP]) Donors (through grants and loan for vertical programs)

MOH services financed through the budget, derived from general revenue (tax) and donations from donors; 80% of services provided by MOH; providers are free and 20% paid

All Egyptian citizens are eligible

Operates: 441 general and district hospitals (62,943 beds) incl. 80 hosp. in Cairo, Giza, Helwan, Qaliobia, and 6th of October governorates, 31 in urban gov’s, 162 in delta gov’s, 128 in Upper Egypt gov’s, 40 in frontier gov’s. Also: 342 urban health care centers: 55 in Cairo, 30 in Helwan, 13 in Alexandria, and 2 in both Matrouh gov. and New Valley (Al Wadi Al Jedid) gov.; 175 maternal-child health and 324 health offices; 3,893 rural health units

TEACHING HOSPITALS AND INSTITUTES ORGANIZATIONS (THIO) THIO is a separate body under the authority of the Minister of Health. Provides primary, secondary, and tertiary services

Coverage: MOH patients, HIO patients, patients from private firms, private patients

MOF MOH (through contract) HIO (through contract) Private firms (through contract) International donors (through grants and loans) Households (OOP spending)

50% of services provided by THIO providers are free and 50% paid

Serves only small percentage of the population

Runs 8 general teaching hospitals and 10 research institutes (5,347 beds): 8 in Cairo, 5 in Giza, and 5 in other governorates

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HEALTH INSURANCE ORGANIZATION (HIO) HIO is an independent government organization under the authority of the Minister of Health

Provides compulsory insurance to workers in the formal sector. Covers 5 major groups: Law 32: Government employees; Law 79: Govt, public, and private employees and labor accident compensation; also widows and pensioners; Law 99: School children and students (under 18 yrs) Decree 380: Newborns

Principally funded through a system of premiums and copayments (by households) Premium collection through: Social Insurance Organization (SIO): mandated premium collected by the SIO Pensions and Insurance Organization (PIO): premium collected from pensioners MOF occassionally covers operating losses

Contracted providers include MOH, CCOs, and private providers

41 million registerd in 2007/08 (approx 55% of total population). This excludes citizens over 65 years who did not register.

Organized into 19 regional branches supervised by headquarters in Cairo. Runs a nationwide network of hospitals, clinics, and pharmacies: 38 hospitals (9,699 beds): 14 in urban governorates, 17 in Lower Egypt, and 7 in Upper Egypt. 59 injury centers Clinics: 8,078 inside schools, 305 outside schools, 1,429 for employees 452 pharmacies in addition to contracted pharmacies Employs 6,748 full-time physicians, 1,482 dentists, 681 nurses, and 1,217 pharmacists

CURATIVE CARE ORGANIZATIONS (CCO)

CCO comprises 3 independent autonomous organizations providing health care services under the authority of the Minister of Health

Coverage: HIO patients, MOH patients (agreed to give a number of beds for MOH, paid in a lump sum) Public and private firms’ patients Households

MOF Self-financing for recurrent costs HIO (via contract to serve HIO beneficiaries) MOH (via contract) Public firms (via contract) Households (by providing services to household)

Contracts services to HIO, MOH, and companies. Provides services to private households. Free emergency services for poor under arrangement with govt. of Egypt (GOE) (via grants from MOH budget). 20% of services provided by THIO providers are free.

100% cost recovery, no subsidies from GOE Only urban patients

Runs 11 CCO hospitals (2,146 beds): 6 in Cairo, 4 in Alex. , and 1 in Qaliobia

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BENEFITS BY HEALTH SUBSYSTEMS

COVERAGE/ SPECIAL CATEGORIES

PRINCIPAL FINANCING

SOURCES

PROVIDER–PAYER RELATIONSHIP

PERCENTAGE OF POPULATION COVERED OR ELIGIBLE

SIZE OF OPERATION

UNIVERSITY HOSPITALS Facilities for teaching and research Autonomous facilities affiliated to individual universities and falling under the responsibility of the Ministry of Higher Education (MOHE)

Provides high-quality care mostly in Cairo area and generates significant resources through user fees. 70% of the coverage is for medical faculty and students; 30% for private households.

MOF through MOHE budget User fees paid directly by households

Primary, secondary, and tertiary treatment

Used predominately by the non-poor population

Operates: 76 hospitals (25,742 beds): 42 in Urban Governorates, 26 in Lower Egypt, and 8 in Upper Egypt

OTHER MINISTRIES

Ministry of Interior (MOI) provides free health and medical care for police and prisoners. Ministry of Transport (MOT) provides services for railway employees. Ministry of Defense (MOD) provides services for the armed forces as well as for local civilians.

MOI: main insured must be a police or prisoner. MOT: main insured must be railway employees. MOD (separate scheme for the armed forces): all primary and secondary covered under this fund

GOE via MOF (general tax revenues) Households

Primary, secondary, and tertiary services (outpatient and inpatient, including medicines)

Interior security forces and their families Railway employees and their families Armed forces and their families

No data available for police hospital. 3 railway hospitals (351) beds. Not possible to ascertain number of hospitals, beds, or doctors employed in the armed forces, but more than 10% of Egyptian physicians are assumed to working in the armed forces. Others operate: 19 other hospitals (1,888 beds)

NONGOVERNMENTAL ORGANIZATIONS (NGOS)

NGOs mostly provide health-related programs; in some cases they provide primary health care medicine and first aid kits to urban and rural organizations to raise public awareness and public health care

All citizens, provided that an application proposal has been lodged through a NGO; sometimes religious organization providing proof that they have the capacity to carry out such activities

Mainly from international NGOs, donors, and donations from large employers, corporations, and companies locally as well as fundraising organized by NGOs. All fundraising activities must be approved.

Primary health care activities and first aid kits mainly through grants and donations from international NGOs

Specific target audiences

The NGO sector as a whole is very tightly regulated by the GOE under law 32 – all NGOs required to have official Ministry of Social Affairs approval to operate. However, only small proportion are registered. Facilities accounted for a total of 401 NGOs.

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BENEFITS BY

HEALTH

SUBSYSTEMS

COVERAGE/

SPECIAL

CATEGORIES

PRINCIPAL FINANCING

SOURCES

PROVIDER –

PAYER

RELATIONSHIP

PERCENTAGE OF

POPULATION

COVERED OR ELIGIBLE

SIZE OF OPERATION

FOREIGN DONORS International aid paid to government and govt employees as population and capital investments. Under authority of the Ministry of International Cooperation

Everyone covered through these programs. Egypt’s health sector and donor-supported projects.

Mainly external governments and organizations

Funds primary health care programs and secondary health services. Much of the aid and vertical programs are in the form of non-economic assistance and are not transferred to the social sectors.

Specific target audiences

Difficulties in compiling information. Foreign donors believed to be insignificant. Multilateral donors: mainly WHO, World Bank, UNFPA, UNICEF, UNDP, African Development Bank, Social Fund for Development. Bilateral donors: mainly USAID, Finland, Holland, and European Union

PRIVATE SECTOR

PRIVATE INSURANCE

Private or voluntary health insurance market is small – the 3 firms offering insurance are all govt-owned parastatals. Many companies make their own arrangements to provide medical care to their employees

All citizens are eligible to use this insurance provided they can afford the premiums

Mainly household OOP spending and employers

Primary and secondary treatment (drugs, outpatient, and inpatient)

All citizens (can choose to access services provided that they can meet the associated cost.

Private insurance companies contract services to public and private providers.

OCCUPATIONAL SYNDICATES

Several groups of professionals and workers organized into occupational association (syndicate). Major syndicates are: medical, commercial, agricultural, and engineering

All members of associations and families are eligible to use services provided by relevant syndicate. Membership is voluntary and is increasing very quickly.

Member of each syndicate and dependents.

Drugs, outpatient and inpatient care

All employees or professionals and their dependents who are syndicate members can access services.

All syndicates contract services to public and private providers.

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PRIVATE HOSPITALS AND PHARMACIES

Owned by individuals and operate in the private sector

All citizens are eligible to use services. Cost of drugs is expensive compared to public pharmacies.

Mainly household OOP spending

Hospital care and drugs

All citizens can access these services offered provided they can pay.

Operates: 1,305 private hospitals (26,814 beds) including: 318 in Cairo, 64 in Helwan, 45 in 6th of October, 187 in Giza, 108 in Alex., 3 in Matrouh, 3 in Luxor, 1 in South Sinai

HOUSEHOLD (OOP) Spending by people on health services provided by health providers

All citizens Mainly from disposable income

Primary, secondary, and tertiary care

All citizens

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ANNEX B: TABLE ES-2 SOURCES TO FINANCING AGENTS

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ANNEX C: TABLE ES-3 FINANCING AGENTS TO PROVIDERS

national health accounts 2007/2008 : egypt report · office of health, infectious disease and...

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